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      • Dental Policies
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    • Community Plan Policies
      • Community Plan Policies
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  • Demographics and Profiles
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  • Administrative Guides and Manuals
    • Administrative Guides and Manuals
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    • Administrative Guide for Commercial, Medicare Advantage and DSNP
      • Administrative Guide for Commercial, Medicare Advantage and DSNP
      • Welcome to UnitedHealthcare 2021 Administrative Guide
      • Quick reference guide 2021 Administrative Guide
      • Introduction
        • Introduction
        • Manuals and benefit plans referenced in the guide
        • Online/interoperability resources and how to contact us
      • Provider responsibilities and standards
        • Provider responsibilities and standards
        • Verifying eligibility, benefits and your network participation status
        • Healthcare plan identification (ID) cards
        • Access standards
        • Network participating care provider responsibilities
        • Civil rights
        • Cooperation with quality improvement and patient safety activities
        • Demographic changes
        • Notification of practice or demographic changes (Applies to Commercial Benefit Plans in California)
        • Administrative terminations for inactivity
        • Member dismissals initiated by a PCP (Medicare Advantage)
        • Medicare opt-out
        • Additional MA requirements
        • Filing a lawsuit by a member
      • Commercial products
        • Commercial products
        • Commercial product overview table
        • Benefit plan types
        • PCP selection
        • Consumer-driven health benefit plans
      • Health Insurance Marketplace (Exchanges)
        • Health Insurance Marketplace (Exchanges)
        • Individual marketplace vs. small business health options program marketplace
        • UnitedHealthcare’s participation in Exchanges
        • What is the health insurance marketplace?
        • Plan coverage and metal levels
        • UnitedHealthcare benefit plans for exchanges
        • Understanding your network participation
        • Verifying eligibility and benefits
        • Plan requirements/features
        • Patient care coordination and case management
        • Telehealth visits
        • Pharmacy
        • Specialty services
        • Claims process
        • Policies and protocols
        • Pharmacy
      • Medicare products
        • Medicare products
        • Medicare product overview tables
        • PCP selection
        • Coverage summaries and policy guidelines for MA members
        • Dual special needs plans managed by Optum
        • Medicare supplement benefit plans
        • Free Medicare education for your staff and patients
      • Referrals
        • Referrals
        • Commercial products referrals
        • Non-Participating Care Provider Referrals (All Commercial Plans)
        • Medicare Advantage Referral Required Plans
        • Individual Advantage Referral Required Plans
      • Medical management
        • Medical management
        • Benefit plans not subject to this protocol
        • Advance notification/prior authorization requirements
        • Advance notification/prior authorization list
        • Facilities: Standard notification requirements
        • How to submit advance or admission notifications/ prior authorizations
        • Updating advance notification or prior authorization requests
        • Coverage and utilization management decisions
        • Pre-service appeals
        • Clinical trials, experimental or investigational services
        • Medical management denials/adverse determinations
        • MA Part C reopenings
        • Outpatient cardiology notification/prior authorization protocol
        • Outpatient radiology notification/prior authorization protocol
        • Medication-assisted treatment (MAT)
        • Trauma services
        • Air Ambulance Licensure
      • Specialty pharmacy and Medicare Advantage pharmacy
        • Specialty pharmacy and Medicare Advantage pharmacy
        • Commercial pharmacy
        • Optum specialty medication guidance program (commercial plans – not applicable to UnitedHealthcare West)
        • Coverage of self-infused/injectable medications under the pharmacy benefit
        • MA pharmacy
        • Drug utilization review program
        • Drug management program (DMP)
        • Medication Therapy Management (MTM)
        • Transition policy
      • Specific protocols
        • Specific protocols
        • Non-Emergent ambulance ground transportation
        • Interoperability protocol
        • Laboratory services protocol
        • Nursing home and assisted living plans
        • Social determinants of health protocol
        • Telehealth services protocol
      • Our claims process
        • Our claims process
        • Optum Pay
        • Virtual card payments
        • Enroll and learn more about Optum Pay
        • Claims and encounter data submissions
        • Risk adjustment data – MA and commercial
        • National Provider Identification (NPI)
        • Medicare Advantage claim processing requirements
        • Claim submission tips
        • Pass-through billing
        • Special reporting requirements for certain claim types
        • Overpayments
        • Subrogation and coordination of benefits
        • Claim correction and resubmission
        • Claim reconsideration, appeals process
        • Resolving concerns or complaints
        • Member appeals, grievances or complaints
        • Medical claim review
      • Compensation
        • Compensation
        • Reimbursement policies
        • Charging members
        • Member financial responsibility
        • Preventive care
        • Extrapolation
        • Audit services
        • Audit failure denials
        • Notice of Medicare Non-Coverage (NOMNC)
      • Medical records standards and requirements
      • Health and disease management
        • Health and disease management
        • Health management programs
        • Case management
        • Commercial health services, wellness and behavioral health programs
        • Commercial consumer transparency tools
        • Medicare Advantage (MA)
        • Commercial and Medicare Advantage behavioral health information
      • Quality Management (QM) program
        • Quality Management (QM) program
        • UnitedHealth Premium® program (commercial plans)
        • Star ratings for MA and prescription drug plans
        • Member satisfaction
        • Imaging accreditation protocol
      • Credentialing and recredentialing
        • Credentialing and recredentialing
        • Credentialing/profile reporting requirements
        • Care provider rights related to the credentialing process
        • Credentialing committee decision-making process (non-delegated)
        • Monitoring of network care providers and health care professionals
      • Member rights and responsibilities
      • Fraud, Waste and Abuse (FWA)
        • Fraud, Waste and Abuse (FWA)
        • Medicare compliance expectations and training
        • Exclusion checks
        • Preclusion list policy
        • Examples of potentially fraudulent, wasteful, or abusive billing (not an inclusive list)
        • Prevention and detection
        • Corrective action plans
        • Beneficiary inducement law
        • Reporting potential fraud, waste or abuse to UnitedHealthcare
      • Provider communication
        • Provider communication
        • Network News: Provider news and updates
        • Network Bulletin: Policy and protocol updates
        • Medical Policy Update Bulletin
        • Other communications
      • All Savers supplement
        • All Savers supplement
        • How to contact All Savers
      • Capitation and/or delegation supplement
        • Capitation and/or delegation supplement
        • What is capitation?
        • What is delegation?
        • How to contact us, Capitation and/or delegation
        • Verifying eligibility and effective dates, Capitation and/or Delegation
        • Commercial eligibility, enrollment, transfers, and disenrollment, Capitation and/or delegation
        • Medicare Advantage (MA) enrollment, eligibility and transfers, and disenrollment Capitation and/or delegation
        • Authorization guarantee (CA Commercial only), Capitation and/or delegation
        • Care provider responsibilities
        • Delegated credentialing program, Capitation and/or delegation
        • Virtual Visits (Commercial HMO plans – CA only)
        • Virtual Visits (Medicare Advantage)
        • Referrals and referral contracting
        • Medical management, Capitation and/or delegation
        • Pharmacy, Capitation and/or Delegation Supplement
        • Facilities, Capitation and/or Delegation Supplement
        • Claims processes, Capitation and/or delegation supplement
        • Claims disputes and appeals, Capitation and/or delegation supplement
        • Contractual and financial responsibilities, Capitation and/or delegation supplement
        • Capitation reports and payments, Capitation and/or delegation supplement
        • CMS premiums and adjustments, Capitation and/or delegation supplement
        • Delegate performance management program, Capitation and/or delegation supplement
        • Appeals and grievances, Capitation and/or delegation supplement
      • Empire Plan supplement
        • Empire Plan supplement
        • Applicability of this supplement
        • Referrals
        • ID cards
        • Prior authorization and notification requirements
        • Online resources and how to contact us
      • Capitation and/or Delegation Supplement
      • Leased Networks
      • Medica HealthCare supplement
        • Medica HealthCare supplement
        • How to contact us, Medica
        • Confidentiality of Protected Health Information (PHI)
        • Referrals
        • Prior authorizations
        • Appeal and reconsideration processes
        • Member rights and responsibilities, Medica
        • Documentation and confidentiality of medical records
        • Provider reporting responsibilities, Medica
      • Mid-Atlantic regional supplement
        • Mid-Atlantic regional supplement
        • Provider responsibilities
        • Referrals
        • Prior authorizations
        • Claims process
        • Capitation
      • Neighborhood Health Partnership supplement
        • Neighborhood Health Partnership supplement
        • How to contact NHP
        • Discharge of a member from participating provider’s care
        • Laboratory services
        • Referrals
        • Utilization Management (UM)
        • Claims reconsiderations and appeals
        • Capitated health care providers
      • OneNet PPO supplement
        • OneNet PPO supplement
        • Who to contact
        • Bills process
        • Referrals
        • Provider responsibilities and workflows
        • Medical records standards and requirements
        • Quality management and health management programs
        • Participant rights and responsibilities
      • Oxford Commercial supplement
        • Oxford Commercial supplement
        • Oxford Commercial product overview
        • How to contact Oxford Commercial
        • Care provider responsibilities and standards, Oxford
        • Referrals, Oxford
        • Utilization management, Oxford
        • Using non-participating health care providers or facilities, Oxford
        • Radiology, cardiology and radiation therapy procedures
        • Emergencies and urgent care
        • Utilization reviews, Oxford
        • Claims process, Oxford
        • Member billing
        • Claims recovery, appeals, disputes and grievances
        • Quality assurance, Oxford
        • Case management and disease management programs
        • Clinical process definitions
        • Member rights and responsibilities
        • Medical and administrative policy updates, Oxford
      • Oxford Level-Funded plans (NJ and CT)
        • Oxford Level-Funded plans (NJ and CT)
        • How to contact us - Oxford Level-Funded plans (NJ and CT) - 2021 UnitedHealthcare Administrative Guide
        • Our claims process - Oxford Level-Funded plans (NJ and CT) - 2021 UnitedHealthcare Administrative Guide
        • How to submit your reconsideration or appeal- Oxford Level-Funded plans (NJ and CT) - 2021 UnitedHealthcare Administrative Guide
      • Preferred Care Partners Supplement
        • Preferred Care Partners Supplement
        • About Preferred Care Partners
        • How to contact Preferred Care Partners
        • Confidentiality of Protected Health Information (PHI), Preferred Care Partners
        • Prior authorizations and referrals, Preferred Care Partners
        • Clinical coverage review, Preferred Care Partners
        • Appeal and reconsideration processes, Preferred Care Partners
        • Member rights and responsibilities
        • Documentation and confidentiality of medical records, Preferred Care Partners
        • Case management and disease management program information, Preferred Care Partners
        • Special needs plans, Preferred Care Partners
        • Care provider reporting responsibilities, Preferred Care Partners
      • River Valley Entities Supplement
        • River Valley Entities Supplement
        • Information regarding the use of this supplement
        • Eligibility, River Valley
        • How to contact River Valley
        • Reimbursement policies, River Valley
        • Referrals, River Valley
        • Utilization Management, River Valley
        • Claims process, River Valley
      • UMR supplement
        • UMR supplement
        • How to contact UMR
        • Health plan identification (ID) cards
        • Prior authorization and notification requirements
        • Clinical trials, experimental or investigational services
        • Pharmacy and specialty pharmacy benefits
        • Medication therapy management
        • Specific protocols
        • Our claims process
        • Health and disease management
        • Frequently asked questions (FAQs)
      • UnitedHealthcare Level Funded supplement
      • UnitedHealthcare West supplement
        • UnitedHealthcare West supplement
        • UnitedHealthcare West information regarding our care provider website
        • How to contact UnitedHealthcare West resources
        • Care provider responsibilities, UnitedHealthcare West
        • Utilization and medical management, UnitedHealthcare West
        • Hospital notifications, UnitedHealthcare West
        • Pharmacy network, UnitedHealthcare West
        • Claims process, UnitedHealthcare West
        • Care provider claims appeals and disputes, UnitedHealthcare West
        • California language assistance program (California commercial plans), UnitedHealthcare West
        • Member complaints and grievances, UnitedHealthcare West
        • California Quality Improvement Committee, UnitedHealthcare West
      • UnitedHealthOne individual plans supplement
        • UnitedHealthOne individual plans supplement
        • How to contact UnitedHealthOne resources
        • Claims process, UnitedHealthOne
        • Member complaints and grievances, UnitedHealthOne
      • Glossary
  • Reports and Quality Programs
    • Reports and Quality Programs
    • CAHPS / HOS
    • Designated Diagnostic Provider
    • Home Health and SNF High-Performing Provider Initiative Lists
    • Hospital Performance
    • PATH
    • Peer Comparison Reports
    • Physician Performance
    • Quality-Based Physician Incentive Program (QPIP)
    • Quality-Based Shared Savings Program (QSSP)
    • Star Ratings Program
    • UnitedHealthcare Capitation, Claim, Quality, Roster and Profile Reports
    • UnitedHealthcare West Capitation, Settlement, Shared Risk Claims, Eligibility, and Patient Management Reports
    • UnitedHealth Premium® Program
  • New User Registration
    • New User Registration
    • Link Self-Service Tools
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Review these bulletins to stay up to date on news, policy changes and other issues important to your practice.

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For Medical Policies, Medical Benefit Drug Policies, Coverage Determination Guidelines, Utilization Review Guidelines and corresponding update bulletins for UnitedHealthcare Community Plan, visit the UnitedHealthcare Community Plan of Kentucky Medical & Drug Policies and Coverage Determination Guidelines page.

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